结肠肝曲癌侵犯门静脉行联合肠系膜上静脉-门静脉切除对端吻合重建手术

目的 探讨结肠肝曲癌侵犯门静脉行右半结肠根治切除(right hemicolectomy,RH)联合肠系膜上静脉-门静脉切除的胰十二指肠切除术(pancreaticoduodenectomy,PD)血管端端吻合的可行性.方法 总结2004-2011年吉林大学普通外科疾病诊疗中心、吉林大学第二医院普通外科行右半结肠根治切除术及胰十二指肠切除、联合肠系膜上-门静脉切除术后血管进行端端吻合5例患者的临床资料.结果 5例患者手术过程均顺利,肿瘤完全切除,无严重术后并发症及围手术期死亡,5例患者均康复出院.结论 结肠肝曲癌极易侵犯胰头十二指肠及(或)门静脉,行右半结肠癌根治切除术及胰十二指肠切除,联合肠系膜上-门静脉切除后均未间置人工血管进行端端吻合是一项安全可行的技术.     

联合血管切除的胰头癌手术安全性分析及18例手术报道

目的探讨联合血管切除在胰头癌根治术中的作用及其安全性。方法回顾性分析2006年1月-2010年4月我科施行18例联合血管切除的胰十二指肠切除术病例的临床资料。结果门静脉(PV)/肠系膜上静脉(SMV)楔形切除5例,门静脉(PV)/肠系膜上静脉(SMV)部分切除、端端吻合9例,门静脉(SMV)/肠系膜上静脉(PV)部分切除自体血管移植2例,SMV/PV部分切除+肠系膜上动脉(SMA)部分切除2例。手术时间5～9小时;术中出血量50～2000ml;门静脉阻断时间20-45分钟。肿瘤切除类型:R0切除10例、R1切除6例、R2切除2例;术后病理证实有6例血管未受侵犯、6例仅侵犯血管外膜、3例侵犯血管中膜、3例侵犯血管内膜;术后并发症发生率22.2%(4/18),主要并发症有胃潴留(2/18)、胆汁瘘(1/18)、胰瘘(1/18)等,无围手术期死亡。结论与传统的胰十二指肠联合切除术相比,联合血管切除并不会增加术后并发症发生率及死亡率,相反会有助于提高局部较晚期肿瘤的切除率特别是R0切除率,改善病人的生存质量。     

游离右侧结肠和肠系膜根部可以避免重建门静脉时使用静脉移植血管

在胰十二指肠切除术常需切除受侵的门静脉 ,如切除长度 4～ 5 cm时则不需静脉移植血管以完成重建 ,可直接行端端吻合。如切除长度较长 ,常需自体静脉或人造血管修复。作者介绍一简易手术方法以直接修复切除 6～ 10 cm的门静脉段。作一长正中切口 ,按常规游离胰头 ,在其颈部切断 ,备作胰十二指肠切除。先结扎脾静脉 ,不需再建脾静脉。如作全胰切除 ,不切断胰颈部 ,在肠系膜上和门静脉旁游离全胰。在连接肠系膜上和门静脉处切断脾静脉。如估计静脉两切端不能拉拢时 ,作下列手术。完全游离右侧结肠、结肠系膜和肠系膜根 ,从十二指肠和胰腺处游…     

胰十二指肠合并肠系膜上静脉-门静脉切除(附25例报告)

目的研究胰十二指肠合并肠系膜上静脉-门静脉切除的手术安全性及术后生存率。方法回顾性分析25例因胰腺癌行胰十二指肠合并肠系膜上静脉-门静脉切除病人，根据病理有无真正的血管侵犯分为A、B两组，A组：无真正的血管侵犯，B组：肠系膜上静脉-门静脉侵犯。结果25例胰十二指肠合并肠系膜上静脉-门静脉切除并发症发生率为32．0％，无一例手术死亡，术后1、2年生存率分别为56．0％、28．0％，A、B两组并发症发生率、术后2年生存率无明显差别。结论肠系膜上静脉-门静脉侵犯并非胰腺癌根治术的禁忌证，只要仔细选择病例，合并肠系膜上静脉-门静脉切除可安全施行，并不增加手术并发症和死亡率。     

胰头癌侵犯门静脉/肠系膜上静脉行胰十二指肠并血管切除和重建术(附五例报告)

目的　探讨胰头癌侵犯门静脉 /肠系膜上静脉行胰十二指肠并血管切除和重建术对进展期胰头癌施行扩大根治性切除的疗效。方法　手术操作步骤同Whipple。在处理血管时首先确认门静脉和肠系膜上静脉肿瘤累及范围 ,阻断门静脉血流。阻断时间 30～ 5 0min ,平均 40min。门静脉 /肠系膜上静脉节段切除 3例 :切除长度 >5cm2例 ,采用Gore Txe人造血管移植 ;血管断端吻合1例。楔形切除 2例 ,予以局部修补。消化道重建采用胰胃吻合 ,胆肠、胃肠吻合术。结果　本组手术时间 5～ 7h ,平均 6h。术中出血 80 0～ 12 0 0ml,平均 10 0 0ml。平均输血 12 0 0ml。术后并发切口裂开 1例 ,顽固性腹水 1例 ,肝功能损害加重 1例。临床治愈 4例 ,因术后肝功能衰竭死亡 1例。结论　胰十二指肠并血管切除和重建是超范围手术 ,应在有条件的医院选择适宜的病例施行。同时 ,必须达到肉眼根治性切除 ,以提高生存率     

胰头癌侵犯门静脉／肠系膜上静脉行胰十二指肠并血管切除和重建术（附五例报告）

目的　探讨胰头癌侵犯门静脉／肠系膜上静脉行胰十二指肠并血管切除和重建术对进展期胰头癌施行扩大根治性切除的疗效。方法　手术操作步骤同Whipple。在处理血管时首先确认门静脉和肠系膜上静脉肿瘤累及范围,阻断门静脉血流。阻断时间30～50min,平均40min。门静脉／肠系膜上静脉节段切除3例：切除长度＞5cm2例,采用Gore-Txe人造血管移植;血管断端吻合1例。楔形切除2例,予以局部修补。消化道重建采用胰胃吻合,胆肠、胃肠吻合术。结果　本组手术时间5～7h,平均6h。术中出血800～1200ml,平均1000ml。平均输血1200ml。术后并发切口裂开1例,顽固性腹水1例,肝功能损害加重1例。临床治愈4例,因术后肝功能衰竭死亡1例。结论　胰十二指肠并血管切除和重建是超范围手术,应在有条件的医院选择适宜的病例施行。同时,必须达到肉眼根治性切除,以提高生存率。     

联合肠系膜上静脉-门静脉切除在胰腺癌根治术中的作用

目的 研究胰十二指肠合并肠系膜上静脉-门静脉切除的手术安全性及术后生存率,评估它在胰腺癌根治术中的作用.方法 回顾性分析32例因胰腺癌行胰十二指肠合并肠系膜上静脉-门静脉切除患者,根据病理有无真正的血管侵犯分为无血管侵犯组和肠系膜上静脉-门静脉侵犯组.结果 32例胰十二指肠合并肠系膜上静脉-门静脉切除并发症发生率为31%,无手术死亡,术后1、3年生存率分别为59%、22%,切缘阴性组平均生存时间20个月,而切缘阳性组平均生存时间仅5.6个月;无肿瘤血管侵犯组和肠系膜上静脉-门静脉侵犯两组并发症发生率、术后3年生存率无明显差别.结论 肠系膜上静脉-门静脉侵犯并非胰腺癌根治术的禁忌证,肠系膜上静脉-门静脉侵犯并非提示不良预后的组织学指标.     

机器人胰腺切除联合血管重建临床分析

目的:探讨机器人胰腺切除联合血管重建的安全性及可行性。方法 :回顾性分析2012年6月至2017年10月我院施行的15例机器人胰腺切除联合血管重建手术病人。8例胰十二指肠切除联合门静脉/肠系膜上静脉重建,1例胰十二指肠切除联合变异右肝动脉重建,2例胰体尾切除联合门静脉重建,2例胰体尾切除联合肝总动脉重建,2例全胰切除联合门静脉或肠系膜上静脉重建。结果:15例机器人胰腺切除联合血管重建手术时间(343±80)(210～540) min。术中出血量(573±310)(200～1 100) mL。术后住院时间(29.8±27.7)(14～122) d。2例(13.3%)病人术后出现胰漏,无死亡病例。结论:机器人胰腺切除联合血管重建安全可行,需手术医师有丰富经验和技术支持。     

胰腺癌根治术联合血管切除中人造血管的采用

近年胰腺癌手术切除率得到明显提高。以往当胰腺癌侵及门静脉（PV）／肠系膜上静脉（SMV）时，常被视为手术切除的禁忌证。但大量研究表明，如果胰腺癌侵犯PV／SMV而无其他远处脏器转移．行联合血管切除的胰头癌扩大根治术仍可获得较好的治疗效果．并对改善病人术后生活质量有一定益处。一般认为，当血管切除长度不超过3～4cm时，可直接行血管吻合。但如果PV切除范围较长而难以直接行端端吻合时。就需应用替代血管进行重建，包括自体血管或人造血管。     

联合肠系膜门静脉切除的胰十二指肠切除术治疗胰头腺癌

胰腺癌侵犯门静脉被视为切除手术的禁忌证，一般认为门静脉系统孤立的肿瘤侵犯是根治性切除的最大障碍。而胰十二指肠切除术中联合肠系膜门静脉切除的价值一直存有争议。本文的主要目的是比较胰头癌病人接受单纯或联合胰十二指肠切除术两组的死亡率、发病率、长期生存率以及术后预后参数。自1989年至2003年，共45例相连续的胰头癌病人接受胰十二指肠切除术，术中发现肠系膜上静脉或（和）门静脉被肿瘤侵犯而联合施行肠系膜门静脉切除（VR＋组）。同期88例胰头部腺癌病人接受了胰十二指肠切除而未联合肠系膜门静脉联合切除术（VR-组）。     

Long Mesentericoportal Vein Resection and End-to-End Anastomosis Without Graft in Pancreaticoduodenectomy

Introduction  The feasibility and safety of pancreaticoduodenectomy (PD) combined with long segmental mesentericoportal vein (MPV; >5 cm) resection and end-to-end anastomosis without graft has rarely been demonstrated. Materials and methods  Eight patients with pancreatic head adenocarcinoma underwent PD combined with long MPV resection between August 2006 and May 2008 in Peking University School of Oncology. Results  By liver mobilization and Cattell–Braasch maneuver, direct and tension-free end-to-end anastomosis was easily performed even when the resected segment of the MPV was longer than 5 cm. All the eight patients experienced uneventful recovery without severe complications. Conclusions  PD with long MPV resection and direct end-to-end anastomoses is safe and effective. Presented at the 15th International Postgraduate Course, IASGO, Athens, Greece, December 13–15, 2007.     

联合门静脉／肠系膜上静脉切除的胰头癌根治术

目的探讨胰头癌侵犯门静脉（portalvein，PV）和（／或）肠系膜上静脉（superior mesentericvein，SMV）时根治切除的可行性。方法回顾分析11例PV／SMV受侵的胰头癌患者临床资料，均行扩大胰十二指肠切除术。其中7例行血管壁部分切除，3例行血管节段性切除及对端吻合，1例行受侵血管切除＋人工血管移植。脾静脉与SMV端侧吻合4例，脾静脉结扎3例。消化道重建采用Child术式。结果本组PV阻断时间平均为18．1（9～32）min。全组患者术后均未发生血管栓塞、肠坏死、肝衰竭等并发症，均康复出院。11例均获随访，时间6～20个月，3例术后1年内死亡，4例术后1—2年死亡，患者平均生存时间15（7～20）个月。结论对单纯侵犯PV／SMV的胰头癌施行联合PV／SMV切除的胰头癌扩大根治术是安全可行的。     

Cephalic pancreaticoduodenectomy with mesentericoportal venous reconstruction. Technical features

Cephalic pancreaticoduodenectomy (CPD) with mesentericoportal venous resection increases the resectability rate of pancreatic tumors. When performed in selected patients and by experienced surgical teams, this technique shows the same long-term rates of morbidity, mortality and survival as CPD without vascular resection, provided that negative surgical margins are obtained. This procedure is contraindicated by complete thrombosis of the portal or superior mesenteric veins, invasion of the superior mesenteric artery or celiac trunk, and distant or periaortic lymph node involvement. Venous reconstruction can be performed through lateral suture, termino-terminal anastomosis, or by graft placement. We believe that intercalation of the autologous internal jugular vein facilitates resection and minimizes phenomena of venous stasis. We present a case of adenocarcinoma of the pancreatic head infiltrating the superior mesenteric-portal vein confluence that underwent surgery in our hospital. CPD with mesentericoportal venous resection and reconstruction using autologous internal jugular vein were performed. The most important technical features are discussed.     

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目的 探讨联合切除血管和重建的胰腺癌根治术的适应征和方法。方法 对上来所放行的区域性胰腺切除术,标准胰十二指肠切除术联合肠系膜上静脉切除的７例胰腺癌作一回顾性分析。结果 ２例行区域性胰腺切除术,其中１例联合切除肝动脉,血管端－端吻合,１例联合切作肠系膜上动脉、肠系膜上静脉,行血管间置移植术;５例行标准胰十二指肠切除术,联合肠系膜上静脉切除血管同置移植术。随访８～６０个月,情况良好,无胰腺癌复发,彩     

门静脉节段切除治疗进展期胰腺癌

目的 研究侵犯门静脉（PV）的胰腺癌的切除方法及治疗效果。方法 对22例胰腺癌患者在施行胰十二指肠切除或胰体尾部切除时清扫区域淋巴结，并联合切除受侵犯的一段PV或肠系膜上静脉（SMV）。结果 行PV或SMV楔形切除修补者6例，节段切除者8例，其中5例行端端吻合，2例行自体大隐静脉移植，1例行肠系膜上静脉下腔静脉转流。平均手术时间7.，平均术中输血600ml，无围手术期死亡。22例患者全部得到随访，存活6个月1例，12个月3例，18个月6例，24个月8例，36个月4例。结信纸 侵犯PV和（或）SMV的胰腺癌切除加广泛淋巴清扫是安全可行的，且能延长患者的生存期。     

Combined portal vein and liver resection for biliary cancer]

Portal vein resection has become common in hepatobiliary resection for biliary cancer with curative intent. When cancer invasion of the portal vein is very limited, wedge resection followed by transverse closure is indicated. Longitudinal closure is contraindicated, as this procedure causes stenosis of the portal vein. In the case of right hepatectomy, segmental resection is feasible before liver transection. Reconstruction is completed with end-to-end anastomosis, in which an intraluminal technique is used for posterior anastomosis and an over-and-over suture for anterior anastomosis. More than 5-cm resection of the portal vein often requires reconstruction with an autovein graft. In the case of left hepatectomy, portal vein resection after liver transection is preferable. The resection and reconstruction method should be determined based on both the extent of cancer invasion of the right portal vein and the length of the right portal trunk. So far, we have aggressively carried out combined portal vein and liver resection in 106 patients with advanced biliary cancer (62 cholangiocarcinoma and 44 gallbladder carcinoma). Twenty-nine patients underwent wedge resections and 77 segmental resections (66 end-to-end anastomosis and 11 autovein grafting using an external iliac vein). In patients with hilar cholangiocarcinoma (n = 58), 3- and 5-year survival rates were 23% and 8%, respectively. Three patients survived for more than 5 years after resection. In contrast, the prognosis of patients with gallbladder cancer (n = 44) was dismal. All of the patients died within 3 years after surgery, although they survived statistically longer than unresected patients. These data suggest that portal vein resection has survival benefit for patients with cholangiocarcinoma. However, the indications for this procedure in gallbladder cancer should be reevaluated.     

门静脉、肠系膜上静脉的解剖与临床应用的初步研究

目的 为提高肝门胆管癌和壶腹周围癌的手术切除率,使该区域受肿瘤浸润的血管能同时切除,血管直接重建提供解剖学依据.方法 在实施肝门胆管癌切除术及胰十二指肠切除术中,对病人的肝蒂内门静脉干、胰腺钩突内的肠系膜上静脉干进行解剖学定位并分段测量长度及可以纵向折叠的长度,以此估计可切除的静脉长度及重新再建血管的长度.结果 测量肝蒂内门静脉干104例,男性(5.8±1.99)cm,女性(5.5±O.81)cm,优势长度大于4.5cm者,男性56例占76.7%,女性25例占80.6%.胰腺钩突内段肠系膜上静脉干测量54例,男性(3.7±0.77)cm,女性(3.5±0.64)cm,优势长度大于3.0cm者,男性28例占77.6%,女性14例占77.8%.门静脉纵向折叠移动的范围在1.8～4.2cm,平均折叠2.2(1.8～2.4)cm者占66.3%,平均折叠2.8(2.5～4.2)cm者占33.7%.切除胰十二指肠后胰腺钩突内肠系膜上静脉段纵向折叠范围平均4.0cm,最长达5.2cm.结论 肝门胆管癌和壶腹周围癌切除术合并受浸血管切除在一定范围是可行的.     

Is pancreaticoduodenectomy with portal vein resection indicated in patients with ductal pancreatic carcinoma?]

Infiltration of the portal vein is almost always regarded as a contraindication for pancreaticoduodenectomy in patients with pancreatic cancer. However, progress in many fields has changed the postoperative situation and mortality of pancreaticoduodenectomy is now below 5%. The aim of the present study was therefore to actually evaluate morbidity, mortality and prognosis of extended pancreaticoduodenectomy combined with protal vein resection for adenocarcinoma of the pancreatic head. Between September 1985 and May 1997 315 patients with a ductal pancreatic carcinoma were treated in our hospital. Resection was possible in 96 cases (partial pancreaticoduodenectomy n = 82, total pancreaticoduodenectomy n = 5, left pancreatic resection n = 9). In 10 cases the portal vein or the mesenteric vein had to be resected. Postoperative complications were seen in 25% of all cases after pancreaticoduodenectomy without portal vein resection and in 20% following extended pancreaticoduodenectomy. The mortality was 5% resp. 0% in both groups. The median survival time of patients after pancreaticoduodenectomy without portal vein resection was 11.9 months (R0 resection: 13.6 months; R1/2 resection 8 months) in contrast to 13.4 months in cases with portal vein resection. In conclusion, these results demonstrate that in special cases of adenocarcinoma of the pancreatic head extended pancreaticoduodenectomy with portal vein resection may be indicated. These patients show a better prognosis than those after palliative procedures. Morbidity and mortality of pancreaticoduodenectomy with portal vein resection is not higher as compared to pancreaticoduodenectomy alone.     

Portomesenteric reconstruction during Whipple procedures: review and report of a case

A 60-year-old man undergoing a Whipple procedure to treat a pancreatic cancer was found to have tumor adherence to the portal vein. An en block pancreaticoduodenectomy with segmental portal vein resection (PVR) was performed. A primary portal vein anastomosis was initially attempted but failed. Hemodynamic deterioration led the authors to perform a temporary prosthetic portal vein interposition graft and abdominal closure. The following morning, once stable, the patient was brought back to the operating room for autologous reconstruction with femoral vein and completion of the pancreaticoduodenectomy. The role of PVR for vein invasion or tumor adherence during a Whipple procedure is still under debate. However, there is growing evidence that the perioperative morbidity and long-term survival in patients who undergo a pancreaticoduodenectomy with PVR are similar to those of patients without vein resection. Therefore a combined resection of the pancreatic head and the portal vein has been suggested in the absence of other contraindications for resection to be able to offer a curative surgical intervention to a larger number of patients. The authors herein report the details of a patient's case and also review the currently available methods for PVR and reconstruction.